August 19, 2022 | By Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT
Training techniques used from the 2021 Documentation Guidelines training and implementation may be helpful with training for these updates as well, even though these updates relate to different types and places of service.
However, a lesson learned from 2021 was that education, by comparison of 1995/1997 guidelines to the new guidelines, may have derailed upgrades to templates and documentation styles. Therefore, as you approach your educational plan, for providers who may be completely green to these documentation guidelines- consider addressing these changes distinct and different from the original as opposed to a comparative format.
Consider the following when creating your educational plan for your providers:
Identify what providers are in need of training and then what training each category will need.
We will start with these 2 categories first:
- Individuals who provide office/clinic services who have received 2021 DG training but provide services in areas impacted by 2023 changes and therefore require additional training.
- Individuals who have NOT received 2021 DG training and who ONLY provide services in areas impacted by 2023 changes and require initial training.
Providers who have been documenting with the 2021 DG and actively receiving audits and feedback since the implementation should be able to attend expedited training sessions as opposed to those who are completely new to the guidelines.
Of course, dividing these into further subsets would best benefit training by having “like” provider subsets attend training together, such as hospitalists in one session, while ED providers have their own training session.
Consider your training dates.
Could CPT changes come at a worse time of the year? With major changes, effective January 1st, the struggle is the timing of the training. If the training starts in October and the beginning of November, providers could “forget” come January when there has been no hands-on use of the knowledge obtained. On the flip side, if you train in November/December, around the holidays, with the sheer energy and chaos of the holiday season, not to mention the patient load, providers retaining the knowledge is yet another concern.
What is the best solution?
There is no penalty for starting the year utilizing existing documentation guidelines- so it may be most advantageous to start the year off using the existing guidelines and then launch a robust initiative of training and implementation in Q1.
Delay of full implementation does not mean you have to fully delay ALL training now. In the months that are leading up to January 1, consider taking existing notes and providing detailed audit notes utilizing 2021 Documentation Guidelines for review. Using a single note bi-weekly can generate conversation and begin to familiarize your providers with some of the changes to assist in the training process. In addition, this approach could help guide conversations on template modification and documentation adaption appropriate for January 1, 2023.
There is no Best Practices Plan that will work for every organization, and as learned from 2021, the best plans can be developed, yet perfect implementation and adaptation still may not exist 2 years later.
The best decision is made with the knowledge we have at that time. The most important consideration for your organization is that a plan is made.
Your next steps:
- Schedule a consultation for 2023 audit planning and a provider documentation review.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
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